So here is something cool: Google three words -- tribes largest employers
-- and dozens of entities pop right up. This is our generation’s
success story because across the country, in communities large and
small, tribal governments and enterprises are writing lots and lots of
pay checks. Tribes are big business.

But that progress takes on a
different context in the age of the Affordable Care Act. Tribes are
employers. And that means there is a long “to do list” in order to meet
the requirements under the healthcare reform law. If a tribe employs
more than fifty workers, then insurance has to be offered that meets the
requirements of the law and costs the employee less than 9.5 percent of
their annual income. (Jim Roberts of the Northwest Portland Area Indian
Health Board wrote an excellent summary of the requirements.)

It’s important to remember
that most Americans, including American Indians and Alaska Natives, get
their health insurance through work. (I’ve written this before and will
add again, this is uniquely American and dumb. We should not tie our
jobs to our health care. But that’s where we are at.)

Right now most of the employer provisions are on hold. The Obama administration gave large employers
more flexibility on insurance rules and delayed the implementation for
mid-size employers until 2016. That means tribes will have more time to
get ready. A good thing, too. Once all of the employer provisions begin,
the penalty for being wrong could cost tribes some $2,000 per employee.

Critics of the Affordable
Care Act are not happy about these changes, saying it’s more evidence
the law does not work. The administration, however, is trying to make
certain there are no more major glitches (such as the web site) and this
is a logical delay.

Another twist that impacts Indian Country is that a major retailer, Target,
is ending its insurance options for part-time employers because the
workers would likely get a better deal through the exchanges (including
tax subsidies). I suspect this would be the same for tribes and tribal
enterprises.

The whole question of
employment under the Affordable Care Act has taken on a new dimension
with the recent report by the Congressional Budget Office. Republican
opponents of the law cited this report as proof that some 2.5 million
people will lose their jobs as a result. The CBO this week refuted that.
The idea the CBO tried to measure was that many people would quit
working because they had more choices.

The back and forth from CBO
is great. “Q: Will 2.5 Million People Lose Their Jobs in 2024 Because
of the ACA? A: No, we would not describe our estimates in that way.”

But, CBO points out, “there
is a broader question as to whether the society and the economy will be
better off as a result of those choices being made available,” a Feb. 10 blog post from director Doug Elmendorf said.
“Even though the individuals making decisions to work less presumably
feel that they will be happier as a result of those decisions, total
employment, investment, output, and tax revenue will be smaller. (Those
effects are included in CBO’s budget and economic projections under
current law.) To be sure, the health insurance system in place prior to
the ACA generated its own distortions to people’s work decisions, but
many of the decisions to work less under the ACA will be made possible
by government-funded subsidies, the burden of which will be borne
largely by other people ... Hence, whether voluntary reductions in hours
worked owing to the ACA are good or bad for the country as a whole is a
matter of judgment.”

I think this particular
debate misses an important point. The Affordable Care Act will free
independent operators because it was too expensive to buy single
policies on the open market. Over time my guess is that more people will
launch a new business because health insurance won’t be a factor. It
will be available and affordable.

But that brings us back to
the political loop. Those that opposed the Affordable Care Act remain
against it. And vice versa. Nothing in the news this week resolves the
deep divisions.

Of course tribes and tribal
enterprises -- large employers, these days -- now have a new means to
contribute resources to the Indian health system. Fully-insured tribal
employees will be a net asset every time they show up at an IHS,
nonprofit or tribally-managed clinic or hospital. Tribal employees will
be the prime customer.